Wednesday, December 30, 2009

Washington Post explores issue of seniors and driving


The Metro Section of the Dec. 30 Washington Post took up the subject of seniors and driving in an article by Ashley Halsey III, “The Crossroads of aging and driving: how old is too old depends, but seniors face a tough choice between safety and mobility; car-dependent communities can become a trap”, link here, p B01 in print.

The article reports that 5533 age 65 or older died in auto accidents, 107 in Va, 83 in MD and 10 in DC (were they all drivers?) Vision tests are required at age 40 or higher in MD and 80 in VA, and persons with disabilities (including early Alzheimer’s) must apply in person in DC. When I was living in Minnesota, a vision test was required at renewal, including peripheral vision

Questions could be asked whether caregivers (adult children) could be liable if allowing disabled seniors to drive. Adult children sometimes take away and hide keys or take off distributor caps. The question could be particularly troubling legally in some states with filial responsibility laws, where adult children could be held responsible for disabled parents or their actions. Many states reserve the right to require seniors to retest for a license upon a senior driver’s receiving a police citation for any moving offense.

But the thrust of the article was that seniors need more “complete communities” in suburban areas, where many services are available on the premises without even the need for bus or metro or taxi, and where assisted living services could be made available when needed.

Monday, December 28, 2009

Health care reform would slowly close Part D "Doughnut hole", but can this be paid for?


In a series called “Health Care Reform 2009” under the Washington Post’s “Politics & The Nation” Amy Goldstein has an important article Monday morning, “The not-so-sweet side of closing the ‘doughnut hole’: Plan widens gap in 2011-2012; Medicare change’s long-term cost uncertain”, link here.

The print version of the paper has a chart on p A3. After a deductible, Medicare picks up ¾ of the cost up to the initial coverage limit, $2700 in 2009. But then the patient must pay for drugs out of her own pocket until reaching the upper limit of $6154. That’s a coverage gap of $3454 in 2009, but in 2010 it will be $3576.

The Senate and House versions, in slightly different ways, would gradually reduce the size of the hole, bringing it to 0 by 2019. Under current law, the coverage gap would expand from $3576 to $6188 in 2019 if the reform were not passed.

The closing of the hole is supposed to be paid for largely by pharmaceutical companies, particularly by encouraging competition, reducing some of their monopoly through the patent process (a very complicated intellectual property issue), forcing them to go generic when possible, and encouraging volume discounts. However Medicare Part D providers (the AARP with United Health Care is the largest) already has negotiated substantial discounts for patients even while in the coverage gap, even for expensive Alzheimers drugs. The involvement of hospice can make the pricing more complicated.

Sunday, December 27, 2009

NY Times runs comprehensive series on end of life


The New York Times is running a series called “Months to Live,” anchored on the front page. The newspaper for Sunday, December 27, 2009 has a very long and detailed article on terminal sedation and palliative sedation, as sometimes carried out in hospices, which according to the article based on practice in New York State, may be based in hospitals. The article gives detailed cases and goes into the ethical and legal issues, which appear not to be completely settled. The link for the story is here.

The article makes reference to a 1997 case before the Supreme Court, Washington v. Glucksberg, Sandra Day O’Connor’s concurring opinion, as well as the majority holding of the court. The link is here.

All of this makes for careful reading.

Saturday, December 26, 2009

Grandparents don't need to be too indulgent with Christmas or Boxing Day gifts


The AARP re-ran on its website a cute article from the New York Times, Dec. 23, “Grandma’s Gifts Need Extra Reindeer,” by Julie Scelfo, link here.

The article goes into indulgent grandparents who want to give their grandchildren so many presents, when parents are concerned about clutter. Surprisingly, media savvy parents are concerned that their kids’ values will become distorted by the offerings of corporations who want to make a profit out of every “fad” that appears in the movies or anywhere in the media. Not that Harry Potter is bad – it gets the grandchildren to want to read – good – but you don’t need all the toys. There will be plenty of blue Na’vi from Avatar around probably, but maybe they provide an opportunity to teach kids about the political and social problems of our own world – or even better, the science of what habitable other worlds will be like. Our grandkids may well live long enough to see real space travel. Will we do EFT deposits of social security checks on a terraformed Mars or even Europa or Titan?

But today’s parents, maybe more that grandparents who are now the babyboomers brought up with TV and in the prosperous 50s and rebellious 60s – know the importance of social development, without so much stuff. It’s our kids – and grandkids – who will have to solve the problems of the world, like stop climate change. Our world will be turned over to them to run, and it better not be for the worse.

Merry Boxing Day!

Thursday, December 24, 2009

Do Social Security and Medicare "undermine" cohesive extended families?


Social conservatives sometimes make the argument that social welfare programs allow individual adults a “false sense of independence” and freedom from responsibility for other adult relatives, a part of life taken for granted until the time of the New Deal, at least.

Particularly, sometimes it is said that social security and Medicare free families from responsibility for their own aged. I found this argument in revisiting Jennifer Roback Morse’s “Love & Economics: Why It Takes a Family to Raise a Village”, a permutation of the title of a well known 90s book by Hillary Clinton. Morse was reviewed on the books blog here Sept. 25, 2008. The point came up again in reviewing Bruce Bartlett’s recent book on the failure of Reaganomics, reviewed yesterday on the books blog.

But are Social Security and Medicare really like “welfare”? Most middle class wage earners experience social security as a “forced savings annuity.” For people with enough covered employment (which is most employment), or legally married to people with enough covered employment, their social security benefits depend roughly on how much they made (up to the FICA-taxable limit) over their working lives. They can start social security earlier (age 62) but at some loss of monthly income (it’s rather steep actuarially) but still the concept is roughly like that of an annuity.

The problem is that the promises to recipients are outgunning the tax and revenue system to support them, and the trust fund mathematics seems to look worse every month. That’s compounded by the fact that people are living longer (drawing benefits longer, which works out badly for people who retired too early -- although there can be the option of paying SSA back and restarting at a higher benefit if you are going to “live longer”).

That’s why libertarians want to replace social security with a privatized (if quasi mandatory) pretax but privatized savings system, with some management to prevent overly risky investments. Theoretically, if everyone took care of themselves this way, government could get out, and adult children would not need to become involved with their parents either; everyone keeps their independence.

But one big problem is that social security originally started in the 1930s as like a “welfare” program for the aged. The original recipients had not contributed taxes, so there is a compounded cost in converting to a privatized system (like Chile) which itself has gotten rather large.

Medicare is, of course, in even more dire straits, but a lot of that is due to inefficiencies (in record keeping, and in unnecessary tests to avoid malpractice suits).

In fact, Medicare does not cover long term care (generally speaking). Seniors must use their own savings and then go on Medicaid or depend on adult children or family members. Up to 28 states have filial responsibility laws or “poor laws” allowing states to pursue adult children for long term care expenses of parents. These are rarely enforced (except in “lookback period” situations where parents gave away assets to kids)

One “problem” is that people are living much longer, without working much longer, and many families are smaller than they used to be. Medicine is able to prolong life, often with inexpensive medications, with good quality, but after 10 or 15 extra years of good quality (even prolonging employment and creativity) there may be a much longer period of disability than would have occurred in past generations, where people often died suddenly of life-threatening diseases while still in their 60s and 70s. Furthermore, at all ages, sophisticated life-extending medical treatments can be contemplated today (like organ or marrow transplants) only in environments where there are cohesive families that can make them work.

That’s why the “age of technology” is curiously leading us back to reconsider our “social contract” again.

Wednesday, December 23, 2009

Part D discounts not always getting applied correctly for people in "doughnut hole"


People using Medicare Part D, or particularly caregivers looking after parents using Part D, should be aware that new medications need to be handled carefully. It seems that sometimes the private insurance carriers (like UHC with AARP) don’t get word on the new medication automatically, and pharmacies may greatly overcharge the patients.

Part D beneficiaries must pay for their own medications while in the “coverage gap” or “doughnut hole” which in 2009 was $2700 to $4350. But the discounted prices for the medications, negotiated by the carrier, should still apply, even when the beneficiary is covering the cost. The negotiated discount on some new medications (which can list for several hundred dollars for 30 pills for anti-cancer drugs or anti-Alzheimers drugs, for example) can be considerable. Pharmaceuticals holding patents on new drugs are charging very high list prices, and only competition or negotiation by large insurance companies or exchanges (under health care reform) can bring prices down. Likewise, older medications with several manufacturers (like atenolol) tend to be very inexpensive because of competition.

There seem to be some issues with the information flow (that is, the I.T. systems) between the insurance carriers, the pharmacies, and the prescribing providers. I’ll look into this more and report on what is really going on soon.

Picture: a miniature "Luxor" (not in Vegas).

Monday, December 21, 2009

Another big story on the dire straits for Social Security, coming soon


In September, this blog linked to some analysis by Sloan and others suggesting that Social Security could run a deficit even by 2010 or 2011. Today MSN greets us with a U.S. News & World Report story, “How long can social security last, link here.
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The average benefit in 2009 was $1155. According to Social Security’s own reports, it will start running a deficit in 2016.

But the latest story has the trust fund exhausted by 2037, after which social security would be able to pay only 75% of promised benefits until 2083.

One proposal is to raise the Social Security earnings cap (from $106,800) by 2% a year until 90% of all earnings are subject to FICA. But an increase in FICA taxes by 2% would also eliminate the deficit.

The real “kicked can” would be means testing, which (if it looked at family structure and “filial responsibility”) could make social security a morally and politically divisive issue indeed.

Thursday, December 17, 2009

SSA makes it official: no "raise" in 2010


Social Security sent all its retirement beneficiaries a greeting this week. It reads, “By law, Social Security benefits increase automatically to keep pace with inflation. When there is a period of no inflation, the law does not permit an increase in benefits. Base on the Consumer Price Index (CPI) published by the Department of Labor, there was no rise in the cost of living the past year, so your benefit will remain the same in 2010.”

My AARP Medicare Part D premium went up 6.8% however at age 66.

Thank you, SSA.

Wednesday, December 16, 2009

"Dear Abby" takes on challenge of eldercare for adult children



Dear Abby yesterday (Dec. 15, 2009) published a syndicated column on eldercare, with many responses, in apparent followup to an earlier letter “Afraid for the Future in San Antonio” that had been published Oct. 25. Apparently her syndicated columns melt away online (I can’t find the Oct. 25 original anywhere; if someone can find a link, please let me know), so all I could find was the set of responses yesterday. The Washington Times published it on p D10, but there are dozens of copies online, such as here at the Philadelphia Inquirer. The letter writer says “people are living longer and prolonging life by any means, so the problem of long-term care and the financial and emotional burdens placed on adult children are very real.”

One could say it’s just payback, or intrinsic family responsibility. In practice, adult children should sit down with their parents and plan for care years before they need it. This is particularly true for childless adult children. The best strategy for many families may be gradual downsizing, encouraging the parent, while well and active to move into a modern, secure urban community for active senior adults, where help will be available later if needed.

The column certainly fits into the warning of the “Dr. David” column, discussed yesterday, and also recently run in The Washington Times.

Tuesday, December 15, 2009

A "Lifelong Health" column from Dr. David Lipschitz warns of huge increases in disability among baby boomers as they live longer; lifestyle choices?


A “Lifelong Health” column from Dr. David Lipschitz, published on p D10 of the Washington Times on December 14, warns “Boomers face rise in disabilities”. The link (hard to find with search engines) is (web URL) here.

David argues that the biggest threat to the American health care system is not just health insurance company behavior as we debate it today, but “the high prevalence of physical or cognitive disabilities in Americans older than 85 that make them dependent on others and no longer able to live alone.”

Later on he remains equally blunt. “Baby boomers are not as healthy as their parents. They do not eat as well, are more sedentary and weight a great deal more. Although this constellation of features does not necessarily shorten life expectancy, it definitely will affect quality of life.”

The American Public Health Association has a link to an abstract of a study to be published in the January 2010 in the American Journal of Public Health, showing a marked increase in change in disability levels of adults 60 and over who participated in the National Health and Nutrition Examination Surveys in 1988 and 1999. Disability rates for people in their 60s has increased rapidly.

So the eldercare debate has been cast by the right wing in terms of “demographic winter” with longer life spans with disability (particularly Alzheimer's Disease) at the end, and fewer children to support them, leaving to “moral” debates about filial responsibility and family values. But the facts show that disability is increasing rapidly at much younger ages, too.

Monday, December 14, 2009

Social security will pay off multiple divorcees


Here’s a social security benefits wrinkle I haven’t covered before, probably because of lack of “personal relevance.” Past multiple wives (or husbands), because of divorce, can file when the wage earning spouse reaches 62 can file for social security benefits on the spouse’s earnings record, without jeopardizing a current spouse’s benefits. There are a couple of caveats: the marriage has to have at least ten years, the divorce must have occurred at least two years ago, and the collecting spouse must not have remarried. The earning spouse does not have to have filed fort benefits.

Yup, heterosexuals can double dip (or multiple dip). Life isn’t fair, is it? This sounds like another “argument for gay marriage” that gay activists have missed.

The facts appear on p 37 of the December 2009 AARP Bulletin, in the “Ask the Experts: Your AARP” column.

Here's SSA's own web reference.

And, Okay, I'm finding the AARP reference online now, URL link (Mon. late PM) here. The AARP print version is a little more expansive.

Saturday, December 12, 2009

Senate-driven Medicare cuts could drive away hospitals, providers from Medicare


Back in 1989 I worked for the ancestor of today’s company Lewin, and even then it focused on hospital operating margins for Medicare, as could broken down into tables and all kinds of categories (DRG, case-mix, rural/urban, etc). I even worked on the “model”. No, I won’t give away any “secrets” – just say that companies around the Beltway get paid to watch this sort of thing. The issues certainly must be alive today after, on Dec. 11, Rick Foster, chief actuary for the Centers for Medicare and Medicaid Services, warned that Medicare cuts proposed by the Senate to help pay for health care reform could drive many providers from Medicare or make them unprofitable. That’s a little odd; the CMS home page (here) links to reports or others sites obviously supported by the Obama administration regarding health reform.
Lori Montgomery has the main story on p A3 of the Saturday Dec 12 Washington Post, “Medicare cuts could hurt hospitals, expert warns,” link here.

This is all ironic given that the Senate also proposes letting pre-seniors at 55 buy in to Medicare.

Here is the current link for Lewin’s published studies on Medicare.

Picture: Virginia Hospital Center in Arlington in winter (recently completed, late 2004).

Friday, December 11, 2009

AARP Medicare Part B Supplementary Premiums creep up as we pull away from 65


My own Medicare Supplementary Part B Premiums from AARP and United Heath Care go up 3.75% in the first half of 2010 and then an effective 8.1% the second half. UHC is mailing out the payment coupons starting Dec 15 but many people use automatic debits. AARP takes the calls and can tell members now their premiums for 2010. I called yesterday to see what would happen -- play Star Reporter -- be a troublemaker!

I started Medicare when I turned 65 in July 2008. Each semester my supplementary premiums have gone up about 4%.

Thursday, December 10, 2009

Medicare Buy-In at 55: Does it really work?


The Washington Post has a constructive editorial “Medicare sausage: The emerging buy-in proposal could have costly unintended consequences,” Thursday, Dec. 10, link here.

This has to do with a proposal to let pre-seniors 55-64 buy into Medicare rather than buy insurance on the exchanges, which may be much better for them (particularly if younger people pay higher premiums and their premiums are regulated).

What I found with retiree health insurance is that even though the premium was somewhat high and paper benefits limited (70% inpatient coverage the last year – fortunately I didn’t have to use it), ING and United Health Care apparently negotiated huge discounts for insured patients, at least at the Virginia Hospital Center and presumably all similar facilities. So a cat scan (which I did need) that started out as $1700 was “only” $370 when covered by insurance, and I had to make a copay of “only” $170 (plus about $20 for the radiologist).

The same practice exists with auto insurance. Body shops charge much less—flat rates --- for repairs covered by insurance.

Saturday, December 05, 2009

New York State "reforms" pensions for its own employees


A New York Times editorial, “A Little Pension Refore”, on Saturday Dec. 5 describes a “reform” in pensions for New York State employees, link here. The reform raises the retirement age to 62 from 55, and limits the amount of overtime pay that can apply to pension calculations.

This reform goes along with the idea that employers need to keep people working longer. I “retired” from private industry at 58, when forced to during a downsizing, with somewhat of a decent pension payment given the amount of service and other circumstances. But that’s not a sustainable pattern for everyone.

Wednesday, December 02, 2009

Congress debates the CLASS Act, to provide help for aging at home; it would not replace long term care insurance!


Check out an AARP story on the proposed "CLASS Act" here.

Michael C. Burgess (R-TX) and Chris Van Hollen (D-MD) debate the proposed the proposed The CLASS (Community Living Assistance Services and Supports) Act to give people assistance at home. However Burgess argues that this does not replace Long Term Care insurance. Burgess also argues LTC insurance ought to generate tax credits, and that parents ought to be considerate enough of their children to purchase it! In states with filial responsibility laws, children could have to foot the bill as Medicaid gets stressed.



Update: Dec. 5

Check a contrasting story in the Saturday Dec 5 New York Times, front page, by Robert Pear, "Home Care Patients Worry Over Possible Cuts", link here, regarding Medicare' home health benefit for treatment for homebound patients.

Update: Dec. 14, 2009

Check a front page article today in the New York Times, by Robert Pear, "Insurance for Long-Term Care in Latest Issue in Health Debate", link here. Ironically, the government expects the CLASS program to help reduce health care deficits by collecting premiums, but in the long run the benefit payments would make the program unsustainable.